Tuesday, July 20, 2010

Tuesday Morning Workday

Tuesday Morning is a little like Monday morning except I'm more tired. The next weekend is closer.
I'm reminded of internship and residency when I'd felt like everyday was a race, 36 hour marathons, barely living from sleep to sleep. Years of chronic fatigue.
The country practice was worse really. Days without sleep, call for 7 days at a time then 2 weeks off call working only 12 hour days,only to be followed for seven days of call and weekends of all night emergencies. We were young then.

When I graduated psychiatry I didn't know anything really. I had my family physician papers and a couple of years of public health and community medicine training plus the newly minted speciality diploma given out by the Royal College of Physicians. I was now a family physician and a psychiatrist with special training in Community Medicine. As a psychiatrist I was fully trained as a psychopharmacologist and a psychiatric psychotherapist.

I started as an assistant professor and was Head of Family Therapy when my own divorce made that all seem such hypocrisy. So I did my American exams and was offered jobs in Carolina, Stanford and Berkeley but stayed at University of British Columbia to study the 'new' psychiatry, "Emergency" and "Crisis Management".

I'd already had a private practice for 6 or 7 years by then, my first patients being psychotherapy patients I saw in the evening. I worked out of my home. Freud always worked out of his home. I saw some people in coffee shops. Adolescents always seemed to be best spoken with at drive ins, eating burgers. If you didn't buy a kid food he didn't talk to you. Those were the rules. That was the profession. I'd been doing home visits as a family physician for years before that. Sometimes I saw people in homes. Not the women. Even then you had to beware of them. Couples were okay. Often I'd go with a nurse, sometimes with the police. The RCMP were the best to go out with late at night.

It was all so different. I didn't know anything. Family medicine simply didn't train one for the insanity or the systemic abuses that transferred to the unconscious workings. I'll never forget the day I stepped in blood and felt how sticky it was, walking through the goo and knowing why it was here and not there.
Hospital psychiatry was so much easier. It was so straight forward. The new doctors always were started in the hospitals. Doctors who couldn't get their full licenses were alllowed to practice there. It was so regimented. All the answers were somewhere in protocol manuals, not that anyone looked in the heat of the moment. But after you could find out what should have gone down, if one had the resources, the personnel, the time or had seen it coming.

I wish sometimes I'd stayed with the easy. I was always moving on to more and more difficult and complex cases.

It was different though. In the north I'd been utterly alone. There were no other specialists or even doctors for days. I'd arrive in a place and a hundred patients would be crowded into the nursing station while the pilot would be saying we had to leave because bad weather was closing in. There'd not been doctor for a month and there'd not be another for another month. Blizzards would make it impossible to fly someone in and out even if there was an emergency. I'd be stranded for days at a time myself.

I never liked dead babies. Didn't like the feel of them in my hands. Didn't like to look at their dead eyes. Skin the wrong temperature as the heat escaped so quickly.

It was then I became disillusioned. I'd studied the laws and politics of health care and saw that it wasn't 'universal'. There were 'haves and have nots' and the dead had no voice and could be quickly forgotten.

Out in the wilderness there were few resources but back in the centres of power and prestige there was infinitely more.

I remember especially that I always could admit someone. As a doctor I was promised resources and the resources I started my career with were hospital beds. A hospital bed is like a gun to a soldier. Since time immemorial doctors had hospitals to fall back on. They could admit people to hospitals so they wouldn't die.

It's like a hockey team without hockey rinks or a football team without a ball.

Overnight, some 20 years ago I was told to practice medicine and psychiatry but that I'd have to do it without any back up. There would be no hospital beds. It wasn't that I'd used them always but it was something that I used and needed.

I think it hit me when I was in the United States and I could admit a sick person overnight or admit someone for the adjustment of their medication for a couple of days. Elective admissions made my life so sweet. For years now I've adjusted medications, sometimes juggling a dozen at a time, in the community without the benefit of a hospital and these days without the patient having family or friends to watch over them.

It's been a decade or two since I've admitted a patient to hospital anyway but with a committal forcing the emergency psychiatrists to keep the patient at least overnight. Also the only patients that have been admitted were acutely suicidal. Suicidality is just one of many reasons for admitting a person to a psychiatric hospital. My patients are often grossly psychotic today walking about on other planets and I'm adjusting their medications relying on a blister pack and sometimes a home visit to see if they are even taking the medications I'm prescribing. Most of these patients have been suicidal many times before and many have been homicidal.

I remembered the WWI soldiers I treated my first years in practice who told me that they'd been sent into war by our government with rifles that didn't work. I think of them sometimes as the years roll on and I remember that I was promised hospital beds when I started medical practice. I remember too there were nurses in the hospital and nurses in the community. I saw a community nurse for the first time in months last week and remembered how there were so many more once. I liked their experience too.

A policeman told me bitterly how she was driving alone in the police car and missed having a partner, how she'd been given a computer but lost her partner and didn't feel safe at night.

I called a colleague and we talked on the phone for 15 minutes about a patient. I remembered how decades back I could call a colleague and they'd see my patient that week. The neurologist I phoned about the patient with the slow growing brain tumor said he could see him in a year. I know psychiatrists who will see my patients for a second opinion in a month or two. If I pulled favours and jumped and shouted and carried on I know I could get a friend to see someone in a day or two, maybe a week. But I know that they're like me. I tell even friends it will be a month or two before I can see their patients.

I remember too when I could see a patient and book them back a week later or even the next day. I feel badly for my secretary who tries to find another slot in the next month or so and I feel that this half hour with this unknown stranger who is suicidal and waited a couple of months to see me and is that much more sicker is going to need therapy but the government wants me to do 'consultations' and refer the patient back to the family physician. The family physician is already seeing people for 5 minute visits and is overbooked because millions upon millions can't get a family physician in Canada. Now a third of my patients only go to walk in clinics where the doctors hand out band aids and referrals.

I liked the sense that I was not so alone in practice. I worked alone for years in the wilderness, no other doctor for hundreds of miles, specialists and facilities thousands of miles away, but I'm in the centre of the city and it's even lonelier. I talk on the phone to family physicians who are as harried as me.

The man was shouting at me that he needed to see me more. He was threatening me saying he needed to see me more and saying that I was a piece of shit to be accepting patients and not having time to see them. I tried to explain that I was a specialist and doing consultations and then offering therapy where possible but that increasingly I could only recommend therapy and the individual had to pay for the therapy I recommended. Half the medications I recommend to people aren't 'covered' by some plan. Only the 'old and used' medications are 'covered'. There's usually reams of paperwork to be done to get anything out of the usual and there's never any time or money for the paperwork. Hundreds of emails.

I remember when my patients had one medication. We were all young then. Now my patients are mostly physically ill with chronic disease and that is coupled with psychiatric illness and more often than not addiction. Increasingly I don't know the names of medications used by cardiologists, nephrologists, endocrinologists. I am daily looking up obscure new medications that we never heard about when I originally studied pharmacology. There's a cocktail of antibiotics for my patients with multiple resistant infections and my HIV patients are always on something new I'm looking up to see if there's a conflict with a medication I'm prescribing.

And the man tells me his father died. He doesn't think he can go on. We sit awhile and there's no one for him to talk to. He'll go home to be with his one friend. He's afraid this one sick friend might die one day and then he'd be truly alone. So many are alienated in the city today.

I'm going to work as a doctor today. I will be in the wilderness of the city again with no hospital, waitlists, and patients without the money for half the things I prescribe and no one with time.

Like all the other doctors we'll be criticized too. Scapegoats. Not good enough. They're bringing in a law that says that doctors can't talk about the conditions they work in. My colleague who complained about his patients dying on the waitlists was called a 'disruptive physician'. Like all doctors today he's afraid for his license.

It was only a decade a go doctors had 'freedom of speech' too but some say that's gone as well.

I talked to the minister of health recently and he really understood. The minister of health really was aware of what was happening and trying to do everything in his power to make things better. I don't know that his superiors were but he was. What was worse though was that those under him were holier than thou. Their attitudes had no place in the scarcity that everyone else was experiencing.

My colleague told me that minions should have to live like normal people for a week or two so they don't have that attitude but then we all know that's their defence. They're usually just young, book learned and inexperinced.They're hurting too. Everyone wants to be loved and no one is loving them any more than they're loving us.

Meanwhile it's time to go to work. It's going to be a good day. We've got along for decades like this. It should be possible to live in the scarcity for another decade. At least I've not bailed out for administration or some other safe and cozy place. I think of going back to the hospital. I love that my friend is doing so well as head of a drug company division. He took the new mandates to heart and gave up old time medicine for the real 'business' of medicine. "I'm in charge of a whole bunch of salesman and it's a whole lot better than the confusion I used to live in with all that criticism from people who thought they knew but had never been where the rubber hit the road." "I paid my dues', he said.

We all have.

- Posted using BlogPress from my iPhone

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